Computers, Medicine, Usability, viewed from the ED
If you're new here, you might like to look through this introduction to the site first.
Are you interested in how computers can reduce medical error?
Did you know that many early medical computer systems increased medical error? (Some current ones, too.)
From your own experience with your own computer at home, do you think that some computers and programs crash on a regular basis? Do you think that most software is hard to use, rude, and frustrating to work with? Based on experience, what you’ve heard, or simple extrapolation, do you suspect that medical computer systems are even worse?
Did you know that the best place to test medical computer systems is the ED, because people working in the ED don’t have the time to deal with bad computer systems, and are intolerant of BS? (If it works in the ED, you can make it work anywhere else in the hospital.)
Do you want to learn more about how to make medical computer systems usable, so as to prevent medical error?
If the answer to any of these questions is “yes,” then read through the Medical Computing series. Although looked at from my viewpoint in the ED, it all applies to medical computer systems wherever they are used, in a hospital, in a clinic or in an office.
If you need a backgrounder on Healthcare IT concepts and terminology, see Healthcare IT in a Nutshell.
There’s also a series of “word” essays that focus on particular and generally more advanced medical computer issues.
To keep up with new postings, you might want to subscribe to my RSS feed.
One final note: Once explained, most of the suggestions on this site seem simple and obvious. But as one is creating a program, or even as one is using a program with a high level of frustration, they are still not obvious until pointed out.
I hope you find the site informative and, perhaps, a bit mind-expandingly entertaining.
Keith Conover, M.D., FACEP

On occasion, an academic paper is published, but one of the following Letters to the Editor or editorial is much more important, with a longer-lasting influence than the original article. An example is an editorial about sore throats/tonsillitis by Dr. Centor, of Centor Criteria fame. Well, now we have similar situation in the field of medical software usability.

An article in the Annals of Emergency Medicine discusses a method to help prevent wrong-patient order entry: introducing a popup with name, age, and sex, chief complaint, bed location, length of stay, and recent medication orders, but also a mandatory 2.5 second pause. If you’re interested in informatics, I don’t recommend the article, as it discusses an inelegant, klunky, duct-tape-type workaround that should never be emulated.

Let’s suppose it is 1980. Suppose someone shows up in your ED with a fever, and a history of travel to an area with a new plague characterized by fever. The nurse has heard about this on the news, asks the patient about travel to the area, and gets a “yes.” The nurse not only writes this on the paper chart, but tells one of the ED doctors about it. The patient is correctly identified as a possible plague carrier, and admitted into an isolation room.

Mid-20th-Century Emergency Room

Let’s now suppose it is 2014. There is a shortage of primary care physicians. Primary care physicians no longer see emergencies, even minor emergencies, in their offices. EDs are much, much busier, and overcrowded. As a way to make things better (and, let’s be honest, to make money), vendors have developed electronic medical record systems (EMRs). Physicians, nurses and other ED staff give these hospital-wide EMRs low grades for usability, but the Federal government has been dangling big bags of money in front of hospital administrators as an incentive to buy an EMR. The government succeeded in persuading hospitals to go ahead full-bore with hospital-wide EMRs irrespective of their poor usability.

Fitts’s Law has been known since Paul Fitts first proposed it in 1954. Wikipedia has a detailed exposition of Fitts’s Law. In essence, it says that “the time required to rapidly move to a target area is a function of the distance to the target and the size of the target.” “Targets that are smaller and/or farther away require more time to acquire.” While this has many applications in industry, we are particularly interested in computer applications, and, specifically, usability of medical software.

Fitts’ Law

We can expand this definition a bit, by being engineers and designers and critics rather than scientists. It is reasonable to assume that the harder something is to do, the more fatigue – mental, physical or both – it will entail.

We know from the Pen-Ivory experiments that paging is better than scrolling. Many vendors are tied to the idea of resizable windows, both due to laziness, and due to user demands to use the maximum space on their monitors. But as with lines of text, increasing the window size may decrease readability and usability.

Many medical applications present us with pages filled with a massive number of small targets. We know that a larger the number of choices on a screen means a more cognitively-tiring process in selecting among them. But there is another dimension to such cluttered pages; when clickable items are widely separated on the page, Fitts’s Law tells us that using the page could be made easier, in both physical and cognitive terms, by decreasing the number of clickable items on the page and increasing their clickable target size. As Strunk and White says: “omit needless clickable items.” (I paraphrase slightly.)

Fitts’s Law is interesting. But for medical applications, where a wrong click may have consequences far beyond navigating to the wrong page, it’s something all developers should keep in the front of their minds. Wrong clicks can kill.

In Icons, Pedagogic Vectors, Forms Design and Posture we briefly discussed icon design. (Icons, in this context, meaning the sketch-pictures on buttons that you can click.) The bottom line was that it’s hard to learn and remember what icons stand for.

I work at the University of Pittsburgh Medical Center. UPMC has prioritized IT, and compared with many other academic medical centers, the IT department is fairly well-funded and well-staffed. The central IT umbrella spreads wide, including 16 major hospitals and numerous other facilities. UPMC uses Cerner for an inpatient electronic medical record (EMR) (and for outpatient settings). For clinical charting in the ED, we use Cerner’s PowerChart 2G, dictating into it using Dragon speech recognition. PowerChart is pretty klunky, as are its templates, and in our ED we use our own very simple PowerChart templates, basically a blank page into which to dictate.We in the ED built some standard templates and macros in Dragon, and docs, including residents, can customize or add new templates or speech macros as they wish, which speeds up dictation quite a bit.

However, we actively discourage the use of the PowerChart templates. Why? Because PowerChart templates have a seductive feature that the vendor and our IT people used to tout. But as it turns out, that feature trashes the signal-to-noise ratio of the chart.